HORMONE THERAPY

The average age when a woman has her last menstrual period is 51 years. Menopause is defined as the absence of menstrual periods for 1 year. The years leading up to menopause often are called perimenopause. This is a time of gradual decrease in estrogen levels and changes in the menstrual cycle. In general, perimenopause lasts from age 45 years to age 55 years, although the timing varies among women. Changing estrogen levels can bring on symptoms such as hot flashes and sleep changes. After menopause, the lack of estrogen can increase the risk of osteoporosis (bone loss). To manage the symptoms of perimenopause, some women may choose to take hormone therapy.

During your childbearing years, monthly changes in the production of two hormones—estrogen and progesterone — bring about your menstrual period. Estrogen has other effects in the body. It helps keep bones strong and helps protect against heart disease. It also keeps the tissues of the vagina moist and elastic. Estrogen and progesterone are made by the ovaries. The ovaries also make other hormones, including the male hormone testosterone. Estrogen causes the endometrium— the lining of the uterus—to grow and thicken to prepare the uterus for pregnancy.

In the middle of the cycle, one of the ovaries releases an egg (ovulation). Following ovulation, levels of progesterone begin to increase. If the woman does not become pregnant, estrogen and progesterone levels decrease. The decrease in pro-gesterone triggers menstruation, or shedding of the lining.

During perimenopause, the ovaries begin to make less estrogen. Some months your ovaries may release an egg; some months they may not. As a result of these changes, your period may become irregular. The number of days between periods may increase or decrease. Your periods may become shorter or longer. Menstrual bleeding may get heavier or lighter. You may begin to skip periods. The event known as menopause happens when you have not had a menstrual period for 1 year.

Hormone therapy means to take estrogen, and in many cases, progestin as well. Progestin is a form of progesterone. Estrogen taken by itself increases the risk of cancer of the endometrium. Taking progestin along with estrogen reduces this risk. If you do not have a uterus (you have had a hysterectomy) , estrogen generally is given alone, without progestin. Estrogen plus progestin is sometimes called “combined hormone therapy.” Estrogen-only therapy is sometimes called “estrogen therapy.”

Systemic Therapy

Hormone therapy can be either “systemic” or “local.” These two terms describe where and how the hormones act in the body. With systemic therapy, the hormones are released into your bloodstream and travel to the organs and tissues where it isneeded. Systemic forms of estrogen include pills, skin patches, gels and sprays that are applied to the skin, and vaginal rings. If progestin is prescribed, it can be given as a pill, patch, gel, or in an intrauterine device. Progestin can be taken separately or combined with estrogen in the same pill or in a patch.

For women taking estrogen-only therapy, estrogen may be taken every day or every few days, depending on the way the estrogen is given.

For women taking combined therapy, there are two types of regimens:

1. Cyclic therapy: Estrogen is taken every day, and progestin is added for several days each month or for several days every 3-4 months.

2. Continuous therapy: Both estrogen and progestin are taken every day.

It is common to have irregular bleeding the first few months of combined therapy use, but within 1 year, bleeding usually stops for most women.

If you are postmenopausal, it is important to tell your health care provider if you have bleeding. Althoughit is often an expected side effect of hormone therapy, it also can be a sign of endometrial cancer. All bleeding after menopause should be evaluated.

Local Therapy

Women with vaginal dryness and thinning of the vaginal lining may be prescribed “local” estrogen therapy in the form of a low-dose vaginal ring, vaginal tablet, or vaginal cream. These forms release small doses of estrogen into the vaginal tissue.The estrogen helps restore the natural thickness and elasticity to the vaginal lining while relieving dryness and irritation.

The tablets and creams usually are used daily at first, then twice or three times a week. The ring is inserted and left in the vagina for 3 months, after which it is removed and a new ring is inserted. You do not have to remove the ring for sexual intercourse.

The signs and symptoms that many women experience during peri-menopause are caused by gradually decreasing levels of estrogen. You may have only a few symptoms, or you may have many. Symptoms may be mild, or they may be severe but hormone therapy can help.

Hot Flashes

About 75% of all women have hot flashes during perimenopause. A hot flash is a sudden feeling of heat that spreads over the face and body. The skin may redden like a blush. You also may break out in a sweat. Hot flashes may last from a few seconds to several minutes or longer. They can occur a few times a month or several times a day, depending on the woman. Hot flashes can happen anytime—day or night. When they occur at night, they can disrupt your sleep. Hot flashes at night also can cause night sweats.

Vaginal Dryness

Loss of estrogen causes changes in the vagina. The lining may become thin and dry. These changes can cause pain during sexual intercourse. They also can make the vagina more prone to infection, which can cause burning and itching.

The urinary tract also changes with age. The urethra (the tube that carries urine from the bladder during urination) can be- come dry, inflamed, or irritated. In some women, this irritation may lead to frequent urination. Women may have an increased risk of bladder infection after menopause.

Hormone therapy has many benefits, but it also has risks. Beginning in 2002, findings of the Women’s Health Initiative, a study by the National Institutes of Health, raised concerns about the risks of both estrogen-only and combined hormone therapy for postmenopausal women. In the years since this study, efforts to clarify the findings have been ongoing. The following sections summarize the latest information about hormone therapy.

Benefits

Both types of hormone therapy (combined and estrogen-only) remain the most effective treatment for the symptoms of peri –menopause.

Both types of hormone therapy help prevent the rapid bone loss that occurs early in menopause. It also has been shown to prevent hip and spine fractures.

Low doses of local estrogen help relieve vaginal dryness and irritation.

Estrogen-only therapy is associated with an increased risk of stroke, gallbladder disease, DVT, and urinary incontinence.

Researchers are continuing to look closely at the risks and benefits of hormone therapy. The average age of the women who were studied in the WHI was 64 years, which is well past the age when menopause starts. Most women who take hormone therapy are in their 40s and 50s and are experiencing perimenopausal symptoms. Research is underway to study whether the risks associated with hormone therapy are related to when therapy is started, how long it is used, and how the therapy is given.

What are menopause and perimenopause?

Menopause is defined as the absence of menstrual periods for 1 year. The average age of menopause is 51 years, but the normal range is 45 years to 55 years.

The years leading up to this point are called perimenopause. This term means "around menopause." This phase can last for up to 10 years. During perimenopause, shifts in hormone levels can affect ovulation and cause changes in the menstrual cycle.

What are some of the common changes that occur in the menstrual cycle during perimenopause?

During a normal menstrual cycle, the levels of the hormones estrogen and progesterone increase and decrease in a regular pattern. Ovulation occurs in the middle of the cycle, and menstruation occurs about 2 weeks later. During perimenopause, hormone levels may not follow this regular pattern. As a result, you may have irregular bleeding or spotting. Some months, your period may be longer and heavier. Other months, it may be shorter and lighter. The number of days between periods may increase or decrease. You may begin to skip periods.

How can I tell if bleeding is abnormal?

Any bleeding after menopause is abnormal and should be reported to your health care provider. Although the menstrual period may become irregular during perimenopause, you should be alert for abnormal bleeding, which can signal a problem not related to perimenopause. A good rule to follow is to tell your health care provider if you notice any of the following changes in your monthly cycle:

Very heavy bleeding

Bleeding that lasts longer than normal

Bleeding that occurs more often than every 3 weeks

Bleeding that occurs after sex or between periods

What are some of the common causes of abnormal bleeding?

Polyps—Polyps are usually noncancerous growths that develop from tissue similar to the endometrium, the tissue that lines the inside of the uterus. They either attach to the uterine wall or develop on the endometrial surface. They may cause irregular or heavy bleeding. Polyps also can grow on the cervixor inside the cervical canal. These polyps may cause bleeding after sex.

Endometrial atrophy—After menopause, the endometrium may become too thin as a result of low estrogen levels. This condition is called endometrial atrophy. As the lining thins, you may have abnormal bleeding.

Endometrial hyperplasia—In this condition, the lining of the uterus thickens. It can cause irregular or heavy bleeding. Endometrial hyperplasia most often is caused by excess estrogen without enough progesterone. In some cases, the cells of the lining become abnormal. This condition, called atypical hyperplasia, can lead to cancer of the uterus. When endometrial hyperplasia is diagnosed and treated early, endometrial cancer often can be prevented. Bleeding is the most common sign of endometrial cancer in women after menopause (see the FAQ Endometrial Hyperplasia).

How is abnormal bleeding diagnosed?

To diagnose the cause of abnormal perimenopausal bleeding or bleeding after menopause, your health care provider will review your personal and family health history. You will have a physical exam. You also may have one or more of the following tests:

Endometrial biopsy—Using a thin tube, a small amount of tissue is taken from the lining of the uterus. The sample is sent to a lab where it is looked at under a microscope.

Transvaginal ultrasound—Sound waves are used to create a picture of the pelvic organs with a device placed in the vagina.

Sonohysterography—Fluid is injected into the uterus through a tube, called a catheter, while ultrasound images are made of the uterus.

Hysteroscopy—A thin, lighted tube with a camera at the end, called a hysteroscope, is inserted through the vagina and the opening of the cervix. The hysteroscope allows the inside of the uterus to be seen.

Dilation and curettage (D&C)—The opening of the cervix is enlarged. Tissue is scraped or suctioned from the lining of the uterus. The tissue is sent to a lab, where it is examined under a microscope.

Some of these tests can be done in your health care provider’s office. Others may be done at a hospital or surgical center.

What treatment is available for abnormal bleeding?

Treatment for abnormal perimenopausal bleeding or bleeding after menopause depends on its cause. If there are growths (such as polyps) that are causing the bleeding, surgery may be needed to remove them. Endometrial atrophy can be treated with medications. Endometrial hyperplasia can be treated with progestin therapy, which causes the endometrium to shed. Thickened areas of the endometrium may be removed using hysteroscopy or D&C.

Women with endometrial hyperplasia are at increased risk of endometrial cancer. They need regular endometrial biopsies to make sure that the hyperplasia has been treated and does not return.